- Two insurers offer plans in the exchange in 2018, one in each county.
- Overall exchange enrollment dropped by more than 15% in 2018
- Proposed Medicaid waiver: work requirement & lifetime coverage limit
Arizona made headlines in the fall of 2016, due to the number of insurers leaving the exchange and the significant rate increases for 2017. But for 2018, Arizona had among the smallest rate increases in the country, with rates virtually unchanged from 2017.
Average pre-subsidy rate increases in Arizona were 57 percent for 2017. Only Oklahoma had a higher average rate increase. And in Arizona’s federally facilitated health insurance exchange, premiums for benchmark plans (second-lowest-cost silver plan, on which subsidies are based) increased an average of 116 percent, the highest of any state. That means subsidies grew sharply in Arizona for 2017.
Rate increases are calculated before any subsidies are applied; subsidies were much larger in Arizona in 2017, offsetting all or most of the rate increase for enrollees who were subsidy-eligible (69 percent of exchange enrollees were subsidy-eligible in 2016; that grew to 86 percent in 2017). For 2018, the subsidy amounts didn’t need to change significantly, given the minor fluctuation in average premiums.
- Blue Cross Blue Shield, for which regulators approved an average rate increase of 51 percent rate for 2017, but a 0.9 percent rate decrease for 2018
- Centene/Ambetter from Health Net, for which an average rate increase of 74.5 percent was approved for 2017, but just a 1.8 percent average rate increase for 2018.
- Although there are two insurers offering plans in the exchange in 2018, every county in the state has just a single insurer option available. That was largely the case in 2017 as well, although Pima County had coverage options from Centene/Ambetter as well as a “catastrophic” plan from Blue Cross Blue Shield. But catastrophic plans are only available to people under 30, and people who have a hardship exemption from the ACA’s individual mandate. So in reality, most enrollees in Pima county only had one insurer option in 2017: Centene/Ambetter from Health Net. And for 2018, Blue Cross Blue Shield of Arizona discontinued their catastrophic plan option in Pima County, leaving each county in the state with a single insurer option available (but multiple plans available from that insurer).
Arizona’s population grew by 25 percent between 2000 and 2010, and the influx continues. We’ve put together a summary of Arizona’s overall public health rankings, ACA history, health insurance options, and Medicare and Medicaid enrollment in recent years.
How Arizona compares in state health rankings
Arizona was rated 29th by the Scorecard on State Health System Performance 2016, which compares the 50 states and the District of Columbia. That’s up from 33rd the year before, but Arizona dropped back to 32nd on the 2017 scorecard. Although Arizona has a low prevalence of smoking and preventable hospitalizations, the state ranks 35th in terms of the percentage of residents without health insurance, and 45th for the percentage of adults with a regular medical home.
Despite enrollment improvements due to the exchange and the expansion of Medicaid, Arizona’s uninsured rates continue to be relatively high, at 15 percent (according to the data used in the Scorecard on State Health System Performance; Census data put Arizona’s uninsured rate at 10 percent by 2016). The best-performing state in terms of the percentage of the population with health insurance is Massachusetts, where only 4 percent of the population was uninsured, according to the Scorecard. Check out Arizona’s Scorecard for more details in terms of how the state ranked in 2017 on a variety of metrics.
Arizona fared about the same for the 2015 edition of America’s Health Rankings, coming in at #30, and remained at about the same level (#31) in the 2017 edition of the Rankings. The state earned 38th and 37th place, respectively, for lack of health insurance and access to primary care physicians.
Visit Key Health Data About Arizona to see how Arizona ranks on additional health indicators, public health readiness measures, and public health funding indicators.
Health status can vary significantly across a state. For a more focused look, review county-by-county ratings for Arizona; this data comes from the Robert Wood Johnson Foundation and the Population Health Institute at the University of Wisconsin.
How has Obamacare helped Arizona’s uninsured?
Arizona participates in the federally facilitated marketplace (HealthCare.gov) and has expanded its Medicaid program under the ACA.
HHS reported that from 2010 to 2015, the number of Arizona residents with health insurance increased by 410,000 as a result of the ACA.
According to U.S. Census data, 17.1 percent of Arizona residents were uninsured in 2013, and that had dropped to 10 percent by 2016
While Arizona’s uninsured rate improved with Obamacare in effect, it remained above the national average (8.6 percent) in 2016 and is still considered high. The state’s efforts to impose a work requirement and five-year lifetime limit could end up rolling back some of the coverage gains, if the Trump Administration approves the state’s latest Medicaid waiver proposal.
2018 insurance carriers
When the first ACA open enrollment began, Arizona’s health insurance exchange was rife with carrier options. The number dropped to 11 in 2015, and then eight in 2016 — Meritus, the state’s Consumer Operated and Oriented Plan was among 12 CO-OPs that had folded by early November 2015.
With Aetna’s departure from the Arizona exchange and Cigna’s decision to exit Maricopa County (the only county where they were planning to offer coverage) at the end of 2016, only two carriers offered 2017 coverage to Arizonans through the exchange. Both of them remained in the exchange for 2018, albeit with far smaller rate increases than they imposed for 2017:
- Blue Cross Blue Shield – approved average rate increase of 51 percent for 2017, but an average decrease of 0.9 percent for 2018.
- Centene/Ambetter from Health Net – approved average rate increase of 74.5 percent for 2017, but just 1.8 percent for 2018.
But coverage with each carrier is localized, with only one insurer offering plans in each county in the state.
That was essentially the case in 2017 as well, when all but Pima County had just a single insurer participating (and even in Pima County, multiple insurer options were only available for people who were allowed to purchase catastrophic plans). For 2018, BCBSAZ cancelled their catastrophic plan in Pima County, leaving each county in the state with just one insurer option for all enrollees.
As of August 2016, Pinal County, Ariz., was without a carrier for 2017 open enrollment, leading Kaiser Health News to call it “an Obamacare ghost town”; however, BCBS of Arizona announced in September 2016 that it had reversed its decision and would continue to sell exchange plans there.
Arizonans enrolled in qualified health plans
Before the exchange opened in the fall of 2013, research by the Kaiser Family Foundation estimated Arizona’s potential market for the health insurance exchange at 551,000 and estimated that 313,000 of those potential consumers would qualify for tax subsidies. Actual results from the 2014 open enrollment period showed that 120,071 people signed up for qualified health plans (QHPs) through Arizona’s health insurance exchange and 144,376 qualified for financial assistance.
During 2016 open enrollment, 203,066 people enrolled in private health plans through Arizona’s exchange. While the initial enrollment was slightly less than it was in 2015, effectuated enrollment as of March 31, 2016, was 8 percent higher than a year prior.
During the 2017 open enrollment period, 196,291 people enrolled in private plans through the Arizona exchange. This was a drop from the year before, but that was the case in most states that use HealthCare.gov. The decline is attributed to uncertainty about the future of the ACA, along with the fact that the Trump Administration scaled back marketing and outreach for HealthCare.gov in the final week of open enrollment.
For 2018 plans, only 165,758 people signed up for coverage during open enrollment. That was more than a 15 percent decline — only West Virginia and Louisiana had enrollment totals that were lower percentages of their 2017 enrollment.
AZ and the Affordable Care Act
In voting on the Affordable Care Act, Sens. John McCain and Jon Kyl voted no. Arizona’s eight representatives split their votes along party lines: the four Democrats voted yes, while the four Republicans voted no. The ACA was signed into law in March 2010.
McCain is still in the Senate, but Kyl has been replaced by Jeff Flake, another Republican who opposes the ACA. In 2017, Flake voted in support of all three of the measures that the Senate considered for repealing the ACA. McCain, however, opposed two of them, and was one of the deciding votes that doomed the GOP’s efforts to repeal the ACA in 2017.
In the House, Arizona still has four Republicans and four Democrats. Their votes on the American Health Care Act (the House GOP bill to repeal the ACA in 2017) were mostly split among party lines, but Republican Rep. Andy Biggs was one of 20 Republican Representatives who voted no on the AHCA.
Former Arizona Gov. Jan Brewer, a Republican, was vocally opposed to the Affordable Care Act, even calling a special legislative session in 2010 to advance her position. Brewer wanted permission to join the lawsuit challenging the healthcare reform law after the state’s Democratic attorney general refused to join the suit.
In the 2010 election, Arizona voters approved a state constitutional amendment barring any state rules or regulations that would force state residents to participate in a healthcare system (federal law supersedes state law, so the ACA’s individual mandate still applies in Arizona).
Despite opposing the overall ACA, Brewer was in favor of state-run health insurance exchange and said it was preferable to a one-size-fits-all model imposed by the federal government. To that end, Brewer established the Office of Health Insurance Exchange, and the state took numerous steps toward setting up a state-run exchange. However, state legislators and a public majority remaining opposed. Brewer ultimately bowed to public sentiment and defaulted to the federally facilitated marketplace.
Brewer was one of several Republican Governors who supported Medicaid expansion despite opposing the ACA in general. Ultimately, Arizona did opt to expand Medicaid under the Affordable Care Act.
Doug Ducey, a Republican, took over the governor’s office in January 2015. During his campaign, he described himself as “100 percent opposed to Obamacare.” Within months of taking office, he signed House Bill 2643 into law, effectively banning the state from creating a state-run exchange. Arizona continues to use HealthCare.gov for enrollments.
Medicaid in Arizona
Arizona Medicaid is called AHCCCS, for Arizona Health Care Cost Containment System.
Former Gov. Brewer followed a different course than most Republican governors and pushed hard for Medicaid expansion in Arizona. A bill authorizing expansion was passed with some Republican support and signed into law by Brewer in 2013.
However, the expansion has been repeatedly challenged. The Arizona legislature in February 2015 passed SB1092, which requires the state to seek an annual waiver from CMS to allow additional eligibility restrictions for Arizona’s Medicaid program – Arizona Health Care Cost Containment System (AHCCCS, which is pronounced “access”). Gov. Ducey signed the bill into law in March 2015.
In September 2016, the Obama Administration CMS approved Arizona’s waiver proposal, but eliminated the most conservative aspects of it. The new waiver runs through September 2021. It implemented a requirement for modest health savings account contributions from enrollees with income above the poverty level, and enrollment in an optional (rather than mandatory) job search program.
CMS did not allow Arizona to implement a work requirement, limit AHCCCS coverage for able-bodied adults to five years, or to charge premiums for people with income below the poverty level. The state also cannot lock people out of AHCCCS for six months if they miss a health savings account contribution, or charge fees for missed health care appointments.
However, the Trump Administration is much more open to the sort of proposals that Arizona made in previous years, and a new Arizona Medicaid waiver is pending CMS approval as of March 2018. The new waiver proposal requests a five-year limit on Medicaid coverage for able-bodied enrollees, along with a work requirement.
With Arizona Medicaid expansion in place for now, 58 percent of uninsured nonelderly people in Arizona are eligible for financial assistance to gain medical insurance coverage through either Medicaid or the marketplace. Forty-two percent of those currently uninsured are not eligible due to immigration status.
Arizona saw a 45 percent increase in monthly Medicaid/CHIP enrollment from 2013 to November 2016, the 14th largest change nationwide. But enrollment plateaued by 2016 (as was the case in most states), and net enrollment was up 43 percent by the end of 2017 — slightly lower than it had been a year earlier. Nationally, the average increase is 29 percent as of the end of 2017, down from 30 percent at the end of 2016.
Learn more about Arizona’s Medicaid program at the Arizona Health Care Cost Containment System website.
Medicare enrollment in the state of Arizona
In 2014, Medicare spent about $8,063 per Arizona enrollee, slightly lower than the national average of $8,970. In 2009, the most recent year for which data is available, Arizona ranked 18th overall in Medicare spending with $8.5 billion annually.
Arizona Medicare recipients who want additional benefits beyond what original Medicare offers can select a Medicare Advantage plan instead, and 38 percent made this choice in 2016. Thirty-one percent of Medicare beneficiaries nationwide were enrolled in Medicare Advantage plans in 2016.
Arizona health insurance resources
Arizona health reform legislation
Here’s what’s happened recently in terms of state-level health care reform legislation in Arizona:
- Gov. Ducey signed HB2643 into law in April 2015. The legislation effectively bans the state from creating a state-run exchange. In 2015, that was an issue due to the uncertainty surrounding the King v. Burwell lawsuit. But in June 2015, the Supreme Court ruled that premium subsidies are legal in every state, regardless of whether the exchange is run by the state or federal government (if the plaintiffs had prevailed, premium subsidies would have disappeared in states like Arizona that rely on the federally-run exchange).
- Also in 2015, SB1092 was signed into law, requiring the state to continue to ask CMS to approve eligibility changes for Medicaid, including a work requirement and a five-year lifetime coverage limit. The Obama Administration rejected most of the major changes that the state wanted to make, but a new waiver proposal, submitted in late 2017, is much more likely to gain approval under the Trump Administration.
Scroll to the bottom of this page for a round-up of other healthcare reform legislation at the state level in Arizona.
Louise Norris is an individual health insurance broker who has been writing about health insurance and health reform since 2006. She has written dozens of opinions and educational pieces about the Affordable Care Act for healthinsurance.org. Her state health exchange updates are regularly cited by media who cover health reform and by other health insurance experts.